Healthcare Provider Details

I. General information

NPI: 1629082375
Provider Name (Legal Business Name): MARK J TULLMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD SUITE 207B
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

670 MASON RIDGE CENTER DR SUITE 300
SAINT LOUIS MO
63141-8573
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-7960
  • Fax: 314-989-0235
Mailing address:
  • Phone: 314-996-7960
  • Fax: 314-989-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number215887-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2011013368
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: